Archived Policies - DME


Hospital Beds and Related Equipment

Number:DME101.001

Effective Date:04-01-2016

End Date:03-31-2017

Coverage:

HOSPITAL BEDS:

Hospital beds (as identified below by type) may be considered medically necessary when meeting specific clinical appropriateness criteria:

Fixed Height (one or more of the following is required):

1. The patient requires positioning of the body to alleviate pain, promote good body alignment, prevent contractures and/or avoid respiratory infection, in ways not feasible with an ordinary bed.

2. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.

3. Pillows or wedges should first have been considered.

4. The patient’s condition requires special attachments that cannot be attached to or used with an ordinary bed.

Variable Height: (in addition to one of the fixed height criteria): The patient requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

Semi-Electric: In addition to the all indications for fixed height and variable height beds, the patient requires frequent or immediate changes in body position.

Total-Electric: This type of bed is rarely indicated except in cases of spinal cord injuries, brain injuries, and patients with neurological damage that prevents them from getting in or out of bed. These patients also require assistance with the basic activities of daily living (i.e., bathing, use of toilet).

Heavy Duty Extra Wide: The patient meets one of the criteria for a fixed height hospital bed and patient weight is more than 350 pounds but does not exceed 600 pounds.

Extra Heavy Duty: The patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds.

SPECIALITY BEDS:

Coverage of an Air Fluidized bed may be considered medically necessary when all of the following criteria are met:

The patient has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure sore; and

The patient is bedridden or chair bound as a result of limited mobility; and

In the absence of an air-fluidized bed, the patient would require institutionalization; and

The bed is ordered by the patient's attending physician based upon a comprehensive assessment and evaluation of the patient after a course of conservative treatment designed to optimize conditions that promote wound healing. The evaluation must be performed within one month prior to initiation of therapy with the air fluidized bed.

The course of conservative treatment must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation to verify that the necessary conservative treatment was rendered. Conservative treatment should include:

1. Frequent repositioning of the patient with particular attention to relief of pressure over prominences (usually every two hours); and

2. Use of support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation; and

3. Necessary treatment to resolve any wound infection; and

4. Optimization of nutrition status to promote wound healing; and

5. Debridement by any means, including wet to dry gauze dressings, to remove devitalized tissue from the wound bed; and

6. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressing protected by an occlusive covering, while the wound heals; and

7. Education of the patient/caregiver in the prevention and management of pressure ulcers; and

8. Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly;

9. Appropriate management of moisture/incontinence.

The availability of a trained adult caregiver to assist with activities of daily living, repositioning, skin care, fluid balance, dry skin care, recognition and management of altered mental status, dietary needs, prescribed treatments and management and support of the air-fluidized bed system and potential problems such as leakage.

Physician directed home treatment regimen with ongoing physician directed assessment.

All other alternative equipment has been considered and ruled out.

Home use of the air-fluidized bed is considered not medically necessary in the following circumstances:

Presence of coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions).

Requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or occlusive material.

Other known contraindications exist.

NOTE: Coverage for the air-fluidized bed is limited to the equipment itself, and does not include reimbursement for the caregiver or, architectural adjustments such as electrical or structural improvements.

Power Flotation Therapy Bed/Alternating Pressure System

May be considered medically necessary if the patient meets one of the following combinations:

Criteria 1, 2 & 3 or

Criteria 4 or

Criteria 5 & 6

Power Floatation Therapy Bed or Alternating Pressure System Criteria Grid

1.

Multiple stages II pressure ulcers located on the trunk or pelvis.

2.

Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate low air loss mattress and/or system.

3.

The ulcers have worsened or remained the same over the past month.

4.

Large or multiple stage III or IV pressure ulcers on the trunk or pelvis.

5.

Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within past 60 days). NOTE: Coverage following a myocutaneous flap or skin graft is generally limited to 60 days from the date of surgery. Continued use of the support surface is covered until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that other aspects of the care plan are being modified to promote healing or use of the support surface is medically necessary for wound management.

6.

Patient has been on an air fluidized bed or power air flotation bed immediately prior to a recent discharge from a hospital or nursing facility.

INSTITUTIONAL BEDS:

Beds in this category may include, but are not limited to, Stryker Frame™, Circulo-Electric™ and Oscillatory bed. These beds are considered not medically necessary as they are considered institutional equipment and inappropriate for home use.

MISCELLANEOUS BEDS:

Beds such as the Craftmatic® Adjustable bed, the Sleep Number® bed by Select Comfort Corporation and the Self Adjusting Technology (SAT™) Bed and the SleepSafe Beds® are considered not medically necessary as they are not hospital beds and are not suited for the appropriate care and treatment of patients.

RELATED EQUIPMENT:

The replacement of a mattress for a medically necessary hospital bed may be considered medically necessary.

An alternating pressure mattress and/or pump or gel/water flotation pad may be considered medically necessary if one of the following combinations is met:

Criteria 1

Criteria 2 or 3 with at least one of criteria 4-7

Alternating Pressure Mattress with Pump, or Gel/Water Flotation Pad Criteria Grid

1.

Completely immobile (patient unable to make changes in body position without assistance).

2.

Limited mobility (patient cannot independently make changes in body position enough to alleviate pressure).

3.

Any stage pressure ulcer on the trunk or pelvis.

4.

Impaired nutritional status.

5.

Fecal or urinary incontinence.

6.

Altered sensory perception.

7.

Compromised circulatory status.

Bed Side Rails

Bed side rails may be considered medically necessary if required by the patient’s condition and are not integral parts of, or an accessory to a hospital bed. Some indications include but are not limited to:

Confusion/disorientation;

Vertigo(dizziness);

Seizures; and

Senile dementia or psychosis.

Bed Cradle

Bed cradles may be considered medically necessary to prevent contact with bed coverings. Some indications include but are not limited to:

Burns;

Gangrene of the feet; and

Impaired circulation in the feet.

Trapeze Bars

A trapeze bar may be considered medically necessary when a patient needs this device to sit up because of a respiratory condition, to change body position for other medical conditions, or to get in or out of bed.

Bed Boards and Over the Bed Tables

These items are considered not medically necessary as they are considered convenience items.

Safety Net Enclosure

The use of safety netting placed over a hospital bed frame or canopy, to prevent falls, is considered not medically necessary. These devices are intended for institutional use only.

NOTE: For further information related to durable medical equipment (DME) see DME101.000 DME Introduction.

Description:

Hospital beds allow the patient's position to be changed at the head and foot of the bed. In addition, the distance of the bed from the floor can be adjusted. In contrast, an ordinary bed has a fixed height from the floor and has no head or leg elevation adjustment.

The following are descriptions of various types of hospital beds:

Fixed height beds have manual head and leg elevation adjustments but not bed height adjustment;

Variable height beds have manual height adjustments and with electric head and leg elevation adjustments;

Semi electric beds have manual height adjustment and electric head and leg adjustments;

Total electric beds have electric height adjustments and electric head and leg adjustments; these additional features allow for motorized adjustment of the height of the bed frame from the floor and are strictly for the convenience of the caregiver. The caregiver may have physical limitations in his/her ability to care for the patient;

A heavy duty extra wide hospital bed is capable of supporting a patient weight between 350 and 600 pounds;

An extra heavy duty bed is a bed able to support patient weight of more than 600 pounds;

An air fluidized therapy bed is a device employing the circulation of filtered air through silicone coated ceramic beads creating the characteristics of fluid. Uses include, treatment and/or prevention of decubitus ulcers, management of severe or extensive burns, and to aid the circulation of blood;

A powered flotation therapy bed is a semi-electric or totally-electric hospital bed with a fully integrated powered pressure reducing mattress, containing a large volume of constantly moving water, air or sand. Uses include treatment and/or prevention of decubitus ulcers, management of severe or extensive burns, and to aid in the circulation of blood.

Miscellaneous beds:

Oscillatory beds were designed to assist with repositioning needs of the critically ill. Using a programmed unit, the bed shifts the position of the patient with minimal stimulation therefore reducing the oxygen demands needed for recuperation.

Beds used in the treatment of spinal cord injuries (Circulo-Electric™ RotoRest™ or Stryker Frame™), are found in facilities such as hospitals.

The Craftmatic® Adjustable bed is a semi-electric bed with head and leg adjustment but no height adjustment. It has a choice of wireless or corded hand wand control that adjusts the head and foot of the bed. An electric mattress cover applies heat to that portion of the body touching the mattress. Dual controls are provided for dual-queen and dual king-size beds. A variety of massage options are available on Craftmatic® Adjustable beds. This type of bed is not a hospital bed.

The Sleep Number® bed has firmness settings between zero and 100 that can be adjusted by a hand held device that electronically adjusts the volume of air. Each side can be independently adjusted. A variety of accessories are available such as pillows, comforters, sheets and mattress pads. This type of bed is not a hospital bed.

The Self Adjusting Technology (SAT™) bed contains an air suspension system with intake and out take valves that are claimed to automatically adjust to each individual regardless of body weight. The design of the bed makes it possible to adjust the volume of air without need for pumps, motors or electricity.

The SleepSafe Beds® address concerns of safety (e.g. entrapment issues and prevention of falls with increased safety rail height). These beds are available with a variety of functions and features (e.g. either electric or non-electric foundations, with or without padding etc).

Rationale:

Coverage for hospital beds must be reasonable and necessary for the treatment of the individual patient. A physician must provide a certificate of medical necessity for the appropriate equipment needed. Medical necessity information should include the diagnosis, a narrative description of the patient's condition, abilities, and limitations and the length of need of the item prescribed. The medical records may include physician’s office records, hospital records, nursing home records, home health agency records, and/or records from other healthcare professionals.

2013 Update

A search of literature through November 2013 identified no new additional information that would change the coverage position of this medical policy.

2016 Update

A search of literature through February 9, 2016 identified no new additional information that would change the coverage position of this medical policy.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

None

HCPCS Codes

E0181, E0182, E0184, E0185, E0186, E0187, E0193, E0194, E0196, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0271, E0272, E0273, E0274, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0373

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Strauss, M.J., Gong, J., et al. The cost of home air-fluidized therapy for pressure sores. Journal of Family Practice (1991 July) 33(1): 52-59.

2. Nimit, K. Public Health Service Assessment Guidelines for Home Air-Fluidized Therapy. Technology Assessments (1989) 5:1-11 Medline (1992 October).

3. Perez, E. and M.D. David. Updated Guidelines for Treatment and Prevention. Geriatrics (1993) 48:39-44.

4. Ochs, R.F., Horn, S.D., et al. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy or Wound Management (2005 February) 51 (2): 38-68.

5. Yonezawa, Y., Miyamoto, Y., et al. A new intelligent bed care system for hospital and home patients. Biomedical Instrumentation and Technology (2005 July-August) 39(4): 313-9.

6. Catz, A., Zifroni, A., et al. Economic assessment of pressure sore prevention using a computerized mattress system in patients with spinal cord injury. Disability and Rehabilitation (2005 November 15) 27(21):1315-9.

7. DMERC Manual Pressure Reducing Support Surfaces Group 1 Chapter 32. (2005). Available at <http://www.medmco.com>.

8. DMERC Manual Pressure Reducing Support Surface Group 2 Chapter 33. (2005). Available at <http://www.medmco.com>.

9. DMERC Manual Pressure Reducing Support Surfaces Group 3 Chapter 33. (2005). Available at <http://www.medmco.com>.

10. Centers for Medicare and Medicaid Services National Coverage Determination (NCD) for Hospital beds (280.7). Available at <https://www.cms.gov.> Last Accessed February 9, 2016.

11. Centers for Medicare and Medicaid Services National Coverage Determination (NCD) for Air fluidized Bed (280.8). Available at <https://www.cms.gov.> Last Accessed February 9, 2016.

12. SleepSafe Beds® The Safety Bed. Product information. Available at<http://sleepsafebed.com>. Last Accessed February 9, 2016.

13. Local Coverage Determination (LCD): Pressure Reducing Support Surfaces – Group 1 (L11563). Available at <https://www.cms.gov>. Last Accessed December 13, 2013.

14. Local Coverage Determination (LCD): Pressure Reducing Support Surfaces – Group 2 (L11564). Available at <https://www.cms.gov>. Last Accessed December 13, 2013.

15. Local Coverage Determination (LCD): Pressure Reducing Support Surfaces – Group 3 (L11565). Available at <https://www.cms.gov>. Last Accessed December 13, 2013.

16. Medicare Policy Regarding Pressure Reducing Support Surfaces – JA1014. Provider Inquiry Assistance. Available at <https://www.cms.gov>.Accessed on February 9, 2016.

Policy History:

Date Reason
4/1/2016 Document updated with literature review. Coverage unchanged.
7/1/2015 Reviewed. No changes.
5/15/2014 Document updated with literature review. The following example was added to the MISCELLANEOUS BEDS statement: SleepSafe Beds®. The wording was changed to include “considered not medically necessary” to the following coverage sections “Bed Boards and Over the Bed Tables” and “Safety Net Enclosure”. CPT/HCPCS code(s) updated.
10/1/2008 CPT/HCPCS code(s) updated
4/15/2008 Policy reviewed without literature review; new review date only. This policy is no longer scheduled for routine literature review and update.
1/1/2008 CPT/HCPCS code(s) updated, medical policy unchanged
10/1/2006 Revised/updated entire document
2/1/2004 Revised/updated entire document
8/1/2002 Revised/updated entire document
9/1/1999 Revised/updated entire document
5/1/1996 Revised/updated entire document
6/1/1991 Revised/updated entire document
5/1/1990 New medical document

Archived Document(s):

Title:Effective Date:End Date:
Hospital Beds and Related Equipment01-15-201910-14-2019
Hospital Beds and Related Equipment04-01-201701-14-2019
Hospital Beds and Related Equipment04-01-201603-31-2017
Hospital Beds and Related Equipment07-01-201503-31-2016
Hospital Beds and Related Equipment05-15-201406-30-2015
Hospital Beds and Related Equipment10-01-200805-14-2014
Hospital Beds and Related Equipment04-15-200809-30-2008
Hospital Beds and Related Equipment10-01-200604-14-2008
Hospital Beds and Related Equipment07-15-200609-30-2006
Hospital Beds and Related Equipment02-27-200407-14-2006
Hospital Beds and Related Equipment08-01-200202-26-2004
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